Application forms

※You do not need to stamp or sign on the samples with circled seal(stamp) marks displayed. However doctor’s stamps are required exceptionally on the documents with stamp fields.

Health insurance eligibility and application-related forms

form example
1 Application Form for Issuance of Health Insurance Eligibility Certificate Example
2 Health Insurance Eligibility Certificate Loss Notification and Application Form for Reissuance Example
3 Dependent Family Member Certification Report －
4 Employment Insurance:"Confirmation Letter" for Unemployment Benefits Example
5 Application Form for Certification as Voluntarily and Continuously Insured Person Example
6 Application Form for Certification as Special Retired Insured Person Example
7 Notification of Change of Address/Name Example
8 Written Notice for Loss of Qualification of Health Insurance Example
9 Notification of Terminate of Health Insurance Dependent Status Example
10 Insurance Premium Refund Request Form for Certification as Voluntarily and Continuously Insured Person Example
11 Insurance Premium Refund Request Form for Certification as Special Retired Insured Person Example
12 Application Form for Cancellation of Registration for Use Individual Number Card as a Health Insurance Card Example

Benefit and claims-related forms

form example
21 Application Form for Medical Care Expenses Example
22 Application Form for Medical Care Expenses (acupuncture, moxibustion)Treatment performed before the end of September 2024 Example
23 Application Form for Medical Care Expenses (acupuncture, moxibustion)Treatment performed after October 2024 Example
24 Application Form for Medical Care Expenses (massage, shiatsu)Treatment performed before the end of September 2024 Example
25 Application Form for Medical Care Expenses (massage, shiatsu)Treatment performed after October 2024 Example
26 Application Form for Overseas Medical Care Expenses Example
27 For medical: attending physician’s statement (form A) －
28 For dental: attending dentist’s statement (form C) －
29 Itemized receipt (form B) －
30 Consent form of medical care expense －
31

Example
32 Injury and sickness allowance agreement(For the first applicaion only) Example
33 Claim for Childbirth and Childcare Lump-sum Grant/ Additional Sum Example
34 Claim for Maternity Allowance Example
35 Childbirth-expense loan application form Example
36 Childbirth-expense loan promissory note －
37 Burial fee (expense) and Additional benetits application form Example
38 Application for payment of health insurance benefits for surviving family members/Notification of Succession of Rights（Only at the time of death of the insured） Exampl
39 Application Form for Transportation Expenses Example
40

Example
41 Ceiling-amount application certificate and loss notification Example
42 Notification of illness or injury due to the act of a third party Example
43 Notification of illness or injury due to the act of a third party (not including car accidents) Example
44 Accident status report Example
45 Memorandum and consent form Example
46 At-home health facility project assistance payment application form －
47 Application for Payment of High Aggregate Cost for Long-Term Care Service Example

Health activities-related forms

form example
51 Health insurance benefit payment certificate application form Example
52 Health promotion seminar application form －
53 Dental and Oral Health Seminar application form －